Theories on Drug Abuse: Selected Contemporary Perspectives

Our three-pronged theory suggests that the incidence of drug dependence will be high in those groups in which there is—

1. Access to dependence-producing substances;

2. Disengagement from proscriptions against their use; and

3. Role strain and/or role deprivation.

A role is a set of expectations and behaviors associated with a specific position in a social system. A role strain is a felt difficulty in meeting the obligations of a role. By role deprivation, we mean the reaction to the termination of a significant role relationship.

A role approach can help to minimize fruitless debates over whether one specific factor is more important than another in the genesis of drug dependence, because role is a sufficiently dynamic concept to subsume a number of other dimensions.

lnstead of having to say that people become drug dependent in order to meet their personality needs, we are suggesting that it is possible to locate the structural sources of role strain and deprivation within the social system. We hypothesize that all points of taking on new roles or all points of being tested for adequacy in a role are likely to be related to role strain and thus to a greater incidence of drug dependence in a group. We also hypothesize that incompatible demands within one role, such as between two roles in the same role set, are likely to lead to a greater incidence of drug dependence.

One clear application of the theory is to persons whose drug of choice is heroin. Heroin users are likely to be persons whose substance use is overdetermined and who have a multiplicity of problems and difficulties, whereas users of other substances are more likely to take them for specific problems (Blum and Blum 1969). Heroin users are therefore persons who are especially likely to experience role difficulties.

DEFENSE-STRUCTURE THEORY (p. 71) Wurmser

Psychodynamically, initiation, repetition, and resumption of compulsive drug use follow a similar, fairly typical pattern that can be summarized in the following circular schema. lt starts out (1) with the narcissistic crisis, leading (2) to overwhelming affects, to an affect regression, a radicalization of these feelings. (3) As direct affect defenses, the closely related phenomena of splitting (ego splits) and fragmentation are deployed. The defense in form mainly of denial, but also of repression and other "mechanisms," is carried out partly by psychological means alone, partly and secondarily by pharmacological propping up (pharmacogenic defense). (4) The latter requires an additional form of defense, the element most specific for this syndrome among

this constellation of seven, the defense by externalization, the importance of reasserting magical (narcissistic) power by external action, including magical "things." (5) This reassertion of power by externalization requires the use of archaic forms of aggression, of outwardly attacking and self-destructive forms of sadomasochism. (6) ln most cases this is only possible by a sudden splitting of the superego and defenses against superego functions. (7) The final point is the enormous pleasure and gratification which this complex of compromise solutions of various instinctual drives with various defenses brings about. Most importantly, the acute narcissistic conflict appears resolved, for the moment, but, as Rado (1933) described, the patient is caught in a vicious circle: "The elation had augmented the ego [now we would say the self] to gigantic dimensions and had almost eliminated the reality; now just the reverse state appears, sharpened by the contrast. The ego is shrunken, and reality appears exaggerated in its dimensions." The patient is not merely back at the start, but on a still lower level of self-esteem.

Continuation

PERSONALITY-DEFICIENCY THEORY (p. 4) Ausubel

To the psychological motivation for drug abuse, i.e., the desire for its adjustive euphoric effects on the part of the inadequate personality, is added the need to continue chronic use in order to avoid unpleasant abstinence symptoms. The latter syndrome, however, is a relatively minor factor in comparison to the addicts' desire for the "high," as they themselves readily admit; the threat of abstinence symptoms only adds an element of uncertainty and urgency to the desire. ln fact, addicts often delay administration of the "fix" because such delay significantly enhances the high.

The relatively minor role of withdrawal symptoms in perpetuating the continuation of all further drug use once addiction occurs is supported by the facts that addicts use up to 30 times the daily dosage needed to suppress withdrawal symptoms; that eventually, in most cases, addicts "shoot" the drug "mainline" to enhance the euphoria (running the risk of septicemia, thrombophlebitis, syphilis, malaria, and hepatitis), when simple hypodermic use would effectively suppress abstinence symptoms; and that many medically addicted normal personalities, who become physiologically dependent in the course of treatment for major surgery, accidents, massive burns, etc., easily overcome their physiological dependence, inasmuch as narcotics have no psychopharmacological adjustive value for them. ln my view, it is difficult to believe that addicts would accept social ostracism and the hazards of supporting their habits simply to avoid an only moderately severe 10-day illness unless opiates had adjustive psychopharmacological value for their particular personality structures.

Claims regarding intracellular "tissue hunger" for heroin following chronic use (Dole and Nyswander 1965, 1967) and the so-called idiosyncratic development of atypically severe withdrawal symptoms that lead to chronic addiction (Lindesmith 1947) appear to me to be purely speculative. The so-called "blockade" value of methadone maintenance in preventing heroin highs (Dole and Nyswander 1965, 1967) is not convincing because no acquired tolerance for any drug is absolute in nature and, in any case, is relative to the doses of both the methadone and the heroin used. Many MMTP (methadone maintenance treatment program) patients admittedly achieve chronic subliminal highs on their

stabilized methadone dose, or even more blatant highs by "doubling up," by discontinuing methadone use prior to shooting heroin, or by using massive doses of heroin.

ADDICTION-TO-PLEASURE THEORY (p. 246)

Bejerot

lt is biologically normal to continue a pleasure stimulation when once begun. To interrupt it spontaneously is associated with cultural attitudes (sin, guilt, and shame), fear of complications, or strong pleasurable stimuli from other sources.

DISRUPTIVE ENVIRONMENT THEORY Cp. 76)

Chain

A positive reaction to heroin does not always occur with the first shot. But the inadequacies that drove a person to trying the first time will encourage him to try again, hoping to capture the increased confidence, the sense of serenity and relaxation he observes in regular users. After a time, he finds that heroin offers pleasurable relief in situations of strain. lf the young person's daily life contains strain and frustration, the relief brought by the drug comes to be welcome at any time. Simultaneously, the drug makes it easy to deny and to avoid facing the deep-seated problems that led to his experimenting with drugs originally.

INCOMPLETE MOURNING THEORY (p. 83)

Coleman

The conceptual foundations of the incomplete loss theory provide the rationale for continuing heroin abuse. The circular, homeostatic model as elaborated by Stanton (1977b) and Stanton and Coleman (1979) explains the means by which drug use is reinforced and maintained. This model is based on a complex set of feedback mechanisms which involve, as a minimum, a triadic family subsystem, most likely mother, father, and drug abuser. ln contradistinction to the linear or causal chain of family events, the circular model suggests that the incomplete mourning of a deceased member (or other loss experience) keeps the family in a continuous grieving process. Because they have not mastered the loss, the drug abuser becomes the revenant of the deceased and is encouraged to stay close to the family. When he or she attempts to leave home, a family crisis ensues and he or she will be "called back." As Coleman and Stanton (1978) and Stanton et al. (1978) suggest, these families would rather have the addict dead than lost to outsiders. The "moving in and moving out" of the addict serves a family maintenance function and preserves the homeostasis. lt is part of the cycle of interlocking behaviors and, if the addict should die.

another member will most likely start to use drugs, insuring the family's enmeshment in an endless cycle of mourning, loss, and mourning.

Bowen (1978) describes a similar cyclical phenomenon among alcoholic families. He suggests that the symptom of excessive drinking occurs when family anxiety is high. The emergence of the drinking stimulates even higher anxiety among those who are dependent on the drinker. The higher the anxiety, the more other family members react by anxiously doing more of what they are already doing. Thus the process of drinking to relieve anxiety and the increased family anxiety in response to drinking can either lead to a functional collapse or the process becomes a chronic pattern.

LEARNED BEHAVIOR THEORY (p. 191) Frederick

The use of drugs is continued largely because of the increase in the habit factor (H) in the equation described in part 1. The increase in the strength of the drug habit is a direct function of the number of reinforcements. As the tension and anxiety are reduced, the strength of the habitual act grows. No other component is necessary to effect a satisfactory explanation of the continuation of drug usage. Habits are the singularly most clearly demonstrable factor in the learning sequence of drug-related behaviors. As the figures chosen to illustrate this phenomenon indicate, one can hypothetically demonstrate how the continuation of drug usage maintains itself by doubling the habit value in the numerator. Thus, drug usage can easily continue for a great length of time, since the probability of drug usage has now reached the value of 1.0. The decay, extinction, and growth of every salient factor inevitably will contribute to the strength of each and, thereby, become manifest in the relationship between constructive and destructive factors to patterns of drug usage. The important thing to remember, however, is the fact that a small increase in the value of a single factor can become both a necessary and a sufficient condition for the development and continuation of drug usage. This is particularly so when a habit has already begun to gain strength in the complex but delicate equation of abusive/addictive behavior. ln substituting the values previously shown, when the small value of (Hd) is doubled in strength, the formula becomes unequivocally abusive/addictive.

Continued use of drugs depends upon users' obtaining the desired cognitive-affective-pharmocogenic effects. lf drug taking helps persons feel good about themselves, decreases their anxiety levels, and most importantly, makes them believe they are in control of their lives, drug taking is likely to continue. Usage is predicted to continue and